ANOTHER NEW ANTI-HYPERTENSIVE COMBO PILL. THIS ONE WITH A DIFFERENCE

I have just read that the US FDA have just approved Edarbyclor by Takeda. This is a combination anti-hypertension pill combining Azilsartan ( an ARB by Takeda ) with chlorthalidone ( a diuretic ). So what, you may say. There are so many combo pills with ARB + diuretic in the marketplace. But please note that this one has chlorthalidone as a diuretic.
One of the great mysteries that I could not understand is why the big pharmas ( Novartis, Pfizer, Boeringher-I, Sanofi, AstraZ ) have all chosen to combine their ARB with hydrochlorthiazide ( HCT ), when all the clinical trials including head-head trials have shown that chlorthalidone is a better anti-hypertensive diuretic then hydrochlorthiazide. This was well shown in SHEP and ALLHAT. There were also a couple of head-head trials. They all concluded that chlorthalidone was a more effective anti-hypertensive than hydrochlorthiazide, with more event reductions too, not just BP control.
At least, Takeda has taken up the challenge, and we wait to see Edarbyclor on our shores. Nothing like how it works in our local population. So far, all the reports have been good. Azilsartan + chlorthalidone was better than Olmesartan and HCT in a head-head trial recently published.
Of course, for our patient's sake, the price will be affordable.

1CARE, PRIORITISE,NOT PRIVATISE.

This response from me was published in Malaysia Kini on 24th Dec 2011

We refer to the letter from the Director-General, Ministry of Health: 'Gov't not abdicating responsibilities thru 1Care' on Dec 17.

We fully agree with the need to improve the quality and delivery of health services for the rakyat, provide more choice to patients and preserve the strengths in our current health system.

Our pubic healthcare system has been inherited from what the British left behind but it is historically not the NHS of the UK

Over the years, Malaysia has improved its own system and adapted it to cater for our needs.

Our robust one-stop GP clinics are the backbone of our primary care system providing basic medical care for more than 60% of outpatients in the nation.

Unlike in the UK, Malaysian patients can walk in to see their GPs without appointment and be attended to in a reasonably short time.

In the UK, to see a GP requires prior appointment which can be two or three days later even if you are down with fever.

To see a specialist in the UK NHS often requires waiting time of up to two months. This is not so in Malaysia. Thus, the Malaysian healthcare system today and the NHS UK are poles apart.

However, the concept paper of reforming our Malaysian HC system (1-Care) tells us that the proposed system is a mirror image of today's NHS which is a system that have failed to deliver and also failed to contain cost.

It has resulted in serious accessibility issues at primary and secondary care. Even the British citizens themselves are upset over the inadequacies of their system.

They are travelling to Europe and even as far as South Africa and India for treatment and surgery.

The proposed transformation will greatly affect the patients and the rakyat and we are naturally deeply concerned with its implications.

The current UK NHS itself undergoing more reforms upon previous reforms.

We have asked many times, why are we heading that way?;

• Reforms but at what cost?;

• How much will this whole 1Care for 1 Malaysia cost the rakyat?

• How will it be financed?;

• Will it mean more taxes, direct or indirect ( as in GST / VAT) ?; and,

• Will the government still be responsible for Healthcare or will it be privatized to government linked companies?

These are all important questions that must be openly addressed.

Past experiences at privatization in Malaysia have been not particularly encouraging. Naturally we are very fearful when it involved healthcare.

Representation of Stakeholders

The Federation has indeed been invited to sit in on the Technical Working Group (TWG) meetings. TWG, as the name suggests, does not deal with the big issues but on nitty gritty details.

The terms of reference TWGs involving the doctors are very limited, and deal mainly with clinical governance, how to charge and what to charge and operational issues of clinics and doctors.

The fact is that the proceedings of the TWGs will be part and parcel of the final blueprint of the proposed system which we believe has already been decided, contrary to what we are told.

Moreover, TWG meetings are often called at short ( sometimes one to two days) notice, making it virtually impossible for many to attend.

However it does give the public the impression that we were invited but did not bother to attend

On the other hand, there are also the TWGs deciding on this healthcare transformation on which conflicted stake holders like private hospital chains, pharmaceutical manufacturers, insurance companies and MCOs meet and decide on the "big money issues".

These meetings are not privy to the patients, doctors, public and the taxpayers.

1-Care will cost more

We expect the cost of proposed reformed healthcare system to push up costs because of the increased administrative cost at the expense of patient care cost.

The 1-Care concept paper has already allocated 5% of the expected total healthcare cost of RM 44.24 billion as administrative cost.

This comes up to a whooping RM2.2 billion each year on administrative costs alone. As doctors we believe that this money should be better spent directly for patient care.

Dr Ng Swee Choon, Medical Affairs Committee Member

Federation of Private Medical Practitioners' Associations Malaysia.

TREATING HYPERTENSION IN THE ELDERLY, AFTER 22 YEARS, WHAT HAPPENS?

Very seldom do we see trial results after 22 years. well, in hypertension, we are seeing. Dr John Kortis and colleagues of New Brunswick, USA reported their SHEP results after 22 years of follow-up. The results is ( in my opinion ), not so wonderful.
SHEP ( systolic Hypertension in the Elderly Program ), began in 1985 when they enrolled 4,700 elderly hypertensives aged average 72years. To half they gave chlorthalidone and the other half placebo. If the treatment arm did not achieve target, they were allowed to add atenolol. After 4.5 years of follow-up, when the trial concluded, of course the treatment arm did better ( less MACCE basically ). Thereafter, all the patients were given chlorthalidone, and treated.
After 22 years, when they tracked the survivors ( 60% had died ). For the rest who were still alive, they found that for every month of treatment during the trial, they lived 1 day longer. Meaning that the treatment arm lived an average of 105 days longer from all cause mortality, and there were 185 fewer CV deaths.
These numbers are not great. But I suppose, the survivors have already, during the trial period less strokes and CV events. So they have benefited, and treating elderly hypertensives, I suppose is mainly to prevent strokes. We now know that treated elderly hypertensives does not prolong life very much ( 1 day for every month of drug therapy ).
The other thing that I did not understand was that, chlothalidone is obviously a better diuretic for treatment benefit, compared to hydrochlothiazide and yet all the big pharmas, use hydrochlothiazide as their diuretic when they made their combo pills like Co-Diovan, Co-Approvel, Micardis Plus, etc. I always felt that it would have been better to have used Diovan plus chlorthalidone, or irbesartan plus chlorthalidone, etc.
I suppose the other comments worth noting is that this trail is one trial where the investigators outlive the patients. Usually after 22 years, the investigators would have also expired.
Anyway, now we know that in the elderly, treatment only confers minimal survival benefit. We have to think that there is better quality of life and a more productive life. That is why we treat them.

THE LOWER THE HEART RATE, THE LONGER THE LIFE.

I have always been intrigue by a table top calender picture given to me earlier, which said that the lower the heart rate, the longer the life. Of course the obvious biological example is the giant Galapagos tortoise which has a resting heart beat of 6 beats per min and an average lifespan of 177 years ( if humans don't kill it ). The mice, on the other hand has a resting heart beat of 240 bpm and a lifespan of 5 years. Interesting. Humans have an average resting heart beat of 60-70bpm and an average lifespan of 70-80 years. Is there any truth in this " 1 billion heart beat per lifespan" theory?
Well, a recent paper by Dr Javaid Nauman of the Norwegian University of Science and Technology, published in the 21st Dec issue of the Journal of the American Medical association, entitled, "Temporal changes in resting heart rate and deaths from ischemic heart disease" will help us to understand this a bit better. It is a simple study. Dr Javaid and colleagues studied 13,499 males and 15.826 females who were part of the Nord-Trondelag County Health Study group. He measured their resting heart beats at baseline and again after 10 years of follow-up. The group also tracked their health records over the 10 years to see who died and from what condition. They found that those who had a rising resting heart rate from 70bpm to 85bpms over the 10 years had a 2x increase risk of dying from heart disease. This would somewhat support the " 1 billion heart beat per lifespan theory". However, they also found that trying to lower the resting heart rate artificially, did not seem to prevent the chance of dying from ischemic heat disease, so that high resting heart rate may be a symptom, rather then the disease. A high resting heart rate may be a reflection of our physical and emotional make-up, maybe our lifestyle and our character, something which we cannot easily change with tablets.
For those who have a simple view of life maybe, who know how to take things easy, you will probably live longer ( naturally I mean ), and for those very "kancheong" people, who are forever worrying about this that the other ( maybe the type As), be careful, you maybe worrying yourself to death.
Remember, the giant Galapagos tortoise has a resting heart beat of 6 and live till 177 years. The lower the heart rate, the longer the life.

BIGTIME CORRUPTION IN MINISTRY OF HEALTH : PROJECT 9BIO.

I was send this piece by a concerned citizen.
It is so sad. Our own doctors are also so corrupt. These people who rule over us never followed our ethics of " First do no harm ".
I have no way of proving if this email is true or false, although I believe that though so sad, it is probably true.

THE CORRIDORS OF POWER

Hakim Joe

Not many Malaysians have heard of 9Bio let alone know what this company is all about but what they should know is that it is a wholly government owned company that has misused, wasted and siphoned away public funds equivalent to the cost of erecting the Petronas Twin Towers.

Ninebio Sdn. Bhd. or 9Bio was launched and conceptualized by the then Minister of Health, Dr. Chua Soi Lek (aka Pornstar), in 2003 but did not receive official government sanction as a National Project until September 2006 when a budget of RM350 million under the 9th Malaysian Plan (9MP) was fast tracked and infused into the company to create an environment whereby research and development of halal vaccines will eventually lead to the mass production of such medicinal products for the Islamic world, making Malaysia the hub of halal vaccine R&D and production worldwide.

Good intentions, superb conceptual marketing, plentiful of funds to kick start the project, officially sanctioned by the Malaysian Government and ably managed by a group of medical professionals. What could possibly go terribly wrong?

Well, nothing because nothing substantial was achieved during the subsequent five years except for the changing of its company name from 9Bio to the Malaysian National Institute for Natural Products, Vaccines and Biologicals, signing a JV agreement with Emergent Bio Solutions Inc. of the US, getting the recognition of the Organization of the Islamic Conference (OIC) as a key center for halal vaccinations, and the tiny issue of a bill submitted by Ekovest-Faber Sdn. Bhd. (a 60%-40% JV company owned by Ekovest Berhad and Faber Group Berhad) to the Government for RM1.9 billion in their capacity as the turnkey contractor for the design, construction, completion and maintenance of the research and development facility on a 784 acre plot in Nilai, Negeri Sembilan (called the Enstek Park).

Inflation works wonders especially in this part of the world.

Apparently 9Bio started off with just one individual - Datuk Dr. Nor Shahidah Khairullah from the Malaysian Ministry of Health who was seconded from the MOH to become the pioneering CEO of 9Bio in January 2007 (with a RM45,000 monthly salary) and nothing irregular was detected until the Jabatan Audit Negara (JAN) reported otherwise in their 2008 Auditor General’s Report, bearing similarities to the National Feedlot Center case. In the report, the AG accounted failures, mismanagement, weaknesses, false claims and financial irregularities on the part of 9Bio’s CEO and a special MOF Tribunal was convened to investigate these findings by the Auditor General.

Part of the AG’s findings also stated, “Datuk Dr. Nor Shahidah binti Khairullah had intentionally: (1) Transferred money from Company’s account in the form of payments to her personal Credit Card account for a totaled sum of RM108,747.60 (USD8,000, GBP6,000, EURO7,700); (2) Transferred money from Company’s account in the form of Traveler’s Cheque under her personal name for a totaled sum of RM21,484.10; (3) Transferred money from Company’s account in the form of Bankers Cheque under her personal name for a totaled sum of RM128,648.40; and (4) Transferred money from Company’s account in the form of Cash via Cash Cheques for a totaled sum of RM208,979.80.”

The Auditor General also recommended that “Datuk Dr. Nor Shahidah should be found guilty for criminal breach of trust (CBT) and cheating when she purposely and intentionally siphoned Company’s money for a totaled sum of RM467,859.90 without the approval of the board of directors.“

Dr. Shahidah did not possess carte blanche when acting on behalf of 9Bio as Dato’ Sri Dr. Mohd. Nasir (MOH Secretary-General) was the 9Bio Chairman and the board of directors included Tan Sri Dr. Ismail Merican (MOH Director-General) and Datuk Ir. Dr. M.S. Pillay (MOH Deputy DG). How was it then possible for Dr. Shahidah to give authorization (for anything to be done that is above the limitation order) without board approval unless it was actually approved by the board of directors?

One. Dr. Shahidah approved the full payment of RM4.1 million consultation fees to Frost & Sullivan, a consultant appointed by 9Bio to prepare a working paper for the proposed manufacturing and process control of the new 9Bio facility in Nilai, even before a single piece of A4 paper was completed by the consultancy firm at the quoted price of RM3.9 million.

Two. The appointment of Frost & Sullivan was done only after twelve months of inactivity by the CEO and the board of directors. 9Bio has failed to submit its business plan to either the MOH or MOF since its inception but company records showed that Dr. Shahidah has already collected RM540,000 in wages and has 52 days of paid leave by the first year on the job.

During the subsequent MOF Tribunal, Dr. Shahidah argued intensely that JAN had no right or executive privilege to question her alleged excessive travel expenses as it was covered by a special Research and Development grant and not by 9Bio. Dr. Shahidah also claimed that prior approval was given by the Ministry of Health’s Director General, Tan Sri Dr. Ismail Merican, for her to travel to Germany and Switzerland. When questioned as to why she was accompanied by a (male) consultant from a different company (Mr. Julian Ding of First
Principles Sdn Bhd) on the trip, Dr. Shahidah stated that she needed the consultant for matters relating to a special project negotiation with Emergent Bio Solutions Inc. When questioned further as to the reasons why she had 9Bio pay for the consultant’s travel expenses when the 9Bio is already paying First Principles RM1.2 million in consultation fees, Dr. Shahidah finally admitted that she had personally approved it without prior obtaining authorization from the 9Bio Board of Directors.

Datuk Dr. Nor Shahidah was subsequently terminated as the CEO of 9Bio and a police report was made with the PDRM and yet another report with the ACA. When Dr. Shahidah was sacked from 9Bio in May 2008, thirty other 9Bio staff resigned voluntarily from the company and (coincidentally) joined Ekovest-Faber.

One question why Dr. Shahidah, a relatively unknown researcher/doctor from the MOH, was specially selected from a group of better qualified and far more experienced candidates to head 9Bio and how she could have accomplished the things (as reported in the 2008 Auditor General’s Report) she attempted within sixteen months as the CEO of 9Bio. Additionally, why was the Director General of the Ministry of Health (Tan Sri Datuk Dr. Hj. Mohd. Ismail Merican), the Deputy DG (Datuk Ir. Dr. Mukundan Sugunan Pillay), and the Secretary General (KSU) of the MOH (Dato’ Sri Dr. Hj. Mohd. Nasir Bin Mohd. Ashraf), as the controlling officer, all protecting and covering up for her?

After the departure of Dr. Shahidah from 9Bio, the MOF decided to take control of the project (from the MOH) and appointed Prof. Dr. Mohd. Azmi Mohd. Lila to become the new CEO of 9Bio. Datuk Ir. Dr. M.S. Pillay was then appointed as the Chairman of 9Bio after retiring from the MOH, the first non-medical (engineer) individual to rise to the number two post in the MOH.

What influence and control did Dr. Shahidah hold over the three men, even to the extent that Tan Sri Dr. Ismail Merican reappointed her as a consultant to the MOH to supervise 9Bio’s purchase of specialized medical manufacturing equipment, irrespective of the on-going PDRM and ACA investigations and regardless of the damning report by the Auditor-General, and for Dato’ Sri Dr. Mohd. Nasir (9Bio’s Chairman) and Datuk Ir. Dr. M.S. Pillay (9Bio’s Executive Director) to agree to this appointment?

It was during this transitional period that Ekovest-Faber hit the MOF with the RM1.9 billion bill. Included with the invoices were six Variation Orders (VO) approved by Dr. Shahidah. So, instead of attempting to determine the basis for the super-duper inflated cost to build the 9Bio facility, the government decided to sweep it all under the proverbial carpet and pay the asking price instead. What’s a couple of billion between friends anyway? Additionally the MOH was just slowly only recovering from its Minister’s admittance of being a porn superstar and the federal elections being around the corner did not help either. The Abdullah government was also concerned by the upcoming PKFTZ scandal in which quite a few Tun(s) were involved and how the accumulation of these losses of public funds could be detrimental to his government seeking another 5-year mandate from the people.

So, instead of correcting an obvious wrong, more public funds were piled into the project to cover it up and this decision could only have been approved by the Fourth Floor. The decision to do so was so hush-hush and the cover up so brilliantly successful that even YB
Lim Kit Siang did not get a whiff of the stench emanating from Putrajaya.

Another thing that was not reported in the AG Report was that when Dato’ Sri Dr. Mohd. Nasir became the 9Bio chairman, one of the first things he did was to approve the rental for temporary office space at Metropolitan Square in Damansara Perdana until the 9Bio facilities in Nilai were completed. It was then reported that 9Bio’s rental (for two floors) amounted to RM61,193 a month and that another RM2 million were spent renovating it (renovation contract awarded to Environ Ventures Sdn. Bhd. by Hotel Ninety Six from
Melaka). Hotel Ninety Six?

Questions remained unanswered and to this day, Dr. Shahidah remains free as both PDRM and MACC has yet to complete their respective investigations. Could the Gang of Four somehow have managed to get away with it?

Rising NCD figures in health survey alarming, says Liow. Star 16th Dec 2011

I have just read my STAR. I read it to keep up with the medical news given by Bernama, and also for the sports. The rest are not worth reading. Anyway, that is another story for another day.
In this morning's Star, The Minister of Health has un-veiled the results of the 4th National Health and Morbidity Survey 2010 ( I presume ).
He mentioned that half of the adult Malaysian population is either over-weight or obese, 30% are hypertensive, and about 20% of adults above 30years of age are diabetic. Only about 7.5% follow a Mediterranean, DASH kind diet and about 65% exercise.
It is always nice to have numbers, so that we know what we are targetting and also know our progress. The numbers are like that of an average developed country ( maybe a touch less ), and a bit higher than a developing country.
The minister also announce the appointment of three 1Malaysia Health ambassadors to encourage Malaysians to adopt healthy lifestyles.
Although I like the numbers given very much, as it helps us health professionals to talk to our patients, I must say that I was rather upset that I could not get a copy of the 4th NHMS results. I suppose it is more important for the minister to announce it than for the medical professional community to study it and have it subjected to peer review. I would like to see the sample size and how the survey was done, to see if it was done properly and whether it can be relied upon. We do not wish to have a system of rubbish in, rubbish out. Politicians are not the best people to judge the validity of a health survey.
We are all very concerned about the rising trend of NCD ( non communicable diseases ), or lifestyle diseases. How should we approach this problem?
Surely, appointing more PR people is not the way to go, or maybe that is not an effective way to go. It would have been more useful, as we have suggested previously, to the last minister of health, to have a concerted effort of mass media and school education, food labelling, and promotion of exercises through having more and safer parks and fields. Whether or not we should stop labelling Malaysia as a food haven, where all kinds of unhealthy food ( like nasi lemak ), are touted as food "that cannot be missed". When certain quarters objected to branding nasi lemak as unhealthy food ( which it is ), the government withdraws and say that there is nothing wrong with nasi lemak ( there is everything wrong, health-wise ), it shows that there is no political will to do the right thing. I can also say the same about roti canai, teh tarik, hokkien mee, and bah kut teh. Do you get the drift. It is not racial. It is for healthy lifestyle.
Teach the children, label the foods so that we know what we are eating. Tax unhealthy food higher, so that we are guided by our pockets to eat healthily. Call it sin food tax. Keep politics out of food, exercise and health.
To reduce NCDs by 15% in the next 10 years, is possible?, I doubt it. I suppose not with this government.

IS IT TIME TO ALLOW PCI IN CENTERS WITHOUT CARDIO-SURGICAL BACKUP?

This has been a question since the advent of angioplasty in 1977. In 1977 when the late Andreas Greuntzig first dilated the proximal LAD lesion. he had cardio-surgical backup. In fact the early work by the Americans in San Francisco, was in the operation theatre with a patient undergoing bypass surgery, trying to see if dilating the plaque will cause important distal embolisation of the plaque. So the early work of angioplasty was done, very much with the cooperation of the cardiac surgeons. When angioplasty first started in Malaysia in October 1998 e had cardio=surgical backup, with an open OT ready, just in case. I had to use it a few times, asking my cardiac surgeon to bale me out.
Then in 1992, we received our stents ( the first generation Palmaz Shatz SDS ), and then we almost never had to summon for cardio-surgical help. It has been almost a decade since we last call for cardio-surgical help. The last time I remembered was when I had to do a left main stem and I asked the cardiac surgeon, if he would take it on, and he declined.
Anyway, with the event of the coronary stents ( and they are so good, slick, easy to deliver and can almost go anywhere ), cardiologist can always bale themselves out well, at the earliest hint of trouble. However, there was still resistance from those in authority to allow PCI in centers without cardio-surgical backup. I know that in Malaysia, some of my colleagues in some private hospitals had to accompany their patient from the other centers to their main KL centers, to do the angioplasty. This is also not good, if you consider the cost to the cardiologist and also the patient and relatives. I believe that if an interventionist does not know how to implant a stent to bale out, he should not be doing angioplasty. And of course, as always, we want all centers to keep their registry, hopefully by a senior nurse, so that all records and experience can be tracked. It is all for patient safety. In fact, all cardiac centers ( including those with cardio-surgical back-up ) should also keep their PCI / cardio-surgical registry. All specialist who do interventions and surgeries should also keep their own registry. It makes us aware of our outcome data.
In the Journal of the American Medical Association 306:2487, 2011, there is an article by Dr Mandeep Singh of the Mayo Clinic, addressing this issue. The article is entitled "PCI in cardiac centers with and without on-site cardiac surgery ". He and his colleagues did a meta-analysis of all controlled trials for the last 20 years, a total of 15 large controlled studies involving PCI in cardiac centers with and with-out cardio-surgical backup. They reviewed 124,074 PCIs in patients undergoing primary angioplasty for STEMI and 914, 288 patients undergoing elective PCIs for nonprimary AMI angioplasty. These are very large numbers and must certainly hold some truth. They found no difference in in-hospital mortality, and emergency CABG. There was absolutely no difference in outcomes between the two groups. They have therefore, rightly I think, call for a review of the AHA / ACC / SCAI clinical guidelines. The guidelines currently states that "PCI maybe considered in centers without on-site cardiac surgery", when initially, it states "not useful/effective and may be harmful". Of course we would rather that it would allow PCI in centers with adequate facilities to do PCI, to their degree of competence.
I can see the reluctance in the US system to allow licence to all PCI centers to do PCI ( even without cardio-surgical back-up ), because of the fear of abuse and insurance payments. Once they open up, there will be a mushrooming of PCI centers in the community hospitals, then the system can pose track, and there may not be enough patient load for the large teaching centers. And of course the third party payers will not be so happy, as they have to pay out more. with more centers doing.
Personally, I think it is about time to allow good people to do PCI in centers without cardio-surgical back-up. How to control is another issue. I have heard of cardiac surgeons telling cardiologist they cannot PCI 2 vessel disease, because the angioplasty list is vetted by the cardiac surgeons. That is ridiculous.
Which is the greater evil. To allow PCI in centers without on-site cardiac surgery or not?
As always it is the professional that is important. You cannot legislate morality and ehical standards, either the cardiologist have it or he does not. In some ways, it reflects how we bring them up. It does look like many have been brought up different from us.

CANCER CHEMOTHERAPY AND CARDIOTOXICITY

Cancers are rapidly catching up with heart disease as the number killer in USA. In Canada, it has already overtaken heart disease as the number one killer, and in Malaysia, it is increasing in importance, but has not yet overtaken heart disease as the number one killer. Nonetheless, we are seeing more and more cancers being diagnosed and undergoing treatment. These treatments are expensive and full of side-effects. This is not surprising as the drugs are meant to damaged and kill malignant cells and will surely also inadvertently kill or damage normal cells especially those cells that are the most rapidly dividing.
Undoubtedly, these agents also can harm cardiac cells, and here, should it occur, may impair heart function and also cause heart failure and death. Cardiologist are often called to evaluate heart function sometimes before the start of chemotherapy and often after chemotherapy has been started, and there were some problems.
Two papers give us a look into the effects of cancer chemotherapy and the heart. Both papers were presented at the ongoing EUROECHO 2011 at Budapest.
The first paper presented, by Dr Helder Dores of Lisbon, Portugal, studied the effects of Trastuzumab or Herceptin on the heart. Herceptin ( as it is commonly known ), is a very effective chemotherapy for Ca Breast. She studied 51 patients with echocardiography, before and 3 months after trreatment. She found that before symptoms of heart failure and LV systolic functions get impaired, the LV diastolic functions become impaired. This happens in almost 20% of patients, and does not seem to be dose related.
The second paper, by Dr Liliana Radulescu of Romania, studied the effects of Epirubicin on malignant tumours of various kinds. She did echocardiograms in all the patients, the 31 who had the chemo only and the 26 patients who had the chemo and also were given lisinopril 10mg and rosuvastatin 10 mg. She found that those patients ( 31 pts ) who only had chemo showed deterioration in LV diastolic function, but those who received chemo and also lisinopril / rosuvastatin, seemed protected from the deterioration in LV diastolic function, showing us that the adverse effects of the chemotherapy ( in this case, Epirubicin ) on the heart, can be prevented.
Obviously, these numbers are small, and should provide a direction for future larger scale studies. They however serves as important early work in an area that will become more and more important.
It may be good for us to take a few lines to review the effects of cancer chemotherapy on the heart. It is wellknown that most of the anthracyclines ( a group of chemotherapy agents commonly used ) will have some form of cardio-toxicity. These may range from LV diastolic dysfunction, to LV systolic dysfunction and heart failure. They may also cause, arrhythmias, hypertension, and also thromboembolism and heart attacks. They can damage plagues and cause them to rupture. It is good medical practice to do an ECG and echocardiogram as baseline before the start of therapy ( especially if anthracyclines are to be used ) so that we can appreciate the deterioration of LV diastolic function, should it occur and prevent the occurrence of LV systolic dysfunction. These chemotherapy cardiac effects may occur immediately upon treatment, or they may be delayed, showing up only years after therapy. And they may not be dose related.
Obviously, there is still much that we need to learn about cancer chemotherapy and the heart, and I am sure, with the rapid increase incidence of cancers, this area of medicine will get more research funds and more work will surely be done.
This will be good for our patients with cancers.

CARDIAC CHANGES IN MARATHONS AND ENDURANCE RACES

As more and more endurance races and marathons are organised every year across the world, cardiologist are getting more and more interested in the physiological changes in the heart during marathon and endurance races. We know for certain that there are fatalities amongst marathon runners. It has variously been quoted as 1:2 million miles run, or 1: 100,000 participants in 26 Km marathons. We also know that marathon running does induce rise in cardiac enzymes, including CPK and troponins.
Dr Andre La Gerche and colleagues of the University of Leuven, Belgium, studied the effects of maranthon and other endurance races ( including triathlons ) in 40 athletes. They had their baseline cardiac enzymes and echocardiogram done to study both their LV and RV volumes and function. These were repeated immediately after the race and also at 1 week later.
They found that the LV volumes and functions were essentially within normal limits. However, in the RV, the volumes were increased immediately post race, compared to baseline and returned to normal at 1 week. The RV functions however were reduced, in proportion to cardiac enzyme rises, and these all return to normal at 1 week.
If this study is correct ( and we need to await more studies to confirm ), then it would appear that in normal athletes, the RV bears the blunt of the insult during endurance races and marathons. This allows the LV to be protected. Obviously, it has much to do with pulmonary function, pulmonary circulation and pressures and gaseous exchange in endurance races.
This paper in published in the Dec 7th European Heart Journal.
If you take a broader view of this paper, it could also teach us that in acute respiratory distress ( in this case, coping with rapid and efficient gaseous exchange and maintaining a good pulmonary circulation ), the RV has alot to do, and to cope. Those of us with chronic lung diseases must know this as people with COAD copes badly with acute respiratory stress, and should avoid such activities.
Anyway, we should keep an open mind as we await more studies on this important topic of coping with marathon and endurance races. I do not think that we have heard the last word on this topic yet.

REPLY TO DG MOH DOCUMENTARY ON HEALTHCARE REFORM IN STAR 3rd Dec 2011

Letter to the Editor, STAR. 3^rd Dec 2011.

I read with great interest the documentary article by the DG of Health in STAR 3^rd Dec 2011.It is so true, that the present Healthcare system, though good by all health outcomes standards measured, needs some improvement. Having said that it is fair to say that, the present system is good compared to some of the developed and developing countries around us. See ( Fig 1 ).

Fig 1. WHO report 2007

What is even better was that even spending 4.75% of GDP on the Total Healthcare ( Public and Private ) in 2009, we are equally good health outcomes. “Syabas” to the government and to all the Healthcare providers. The DG stated that the government spends only 55% of the total expenditure while 45% is from private funding. That means that the government expenditure is only about 3% of GDP. This is far from the OECD average of 9.7% of GDP.

There is no guarantee that transforming the whole system to an NHS-like system will improve things. Taking care of our people is to take care of our workforce, so that we have a healthy workforce to achieve vision 2020. It is absolutely vital that the government of the day give more emphasis and more money to provide good healthcare for a stronger workforce.

Fig 2. PUBLIC & PRIVATE HEALTH EXPENDITURE AS % OF GDP, 1997-2008. MNHA 2009

From what I understand from the DG’s article, a few points may have been lost in translation. It is important to note that all health insurance system work on rationing care. The system provider have to see which condition to re-imburse and which not to re-imburse. That means that some condition will not be covered. That is how they cut cost. Besides choice of conditions covered, patients also lose their choice of consultants / specialist to take care of them. They are assigned specialist and consultants. That to them is cost savings. This cost cutting in turn pays for the management overhead of the insurance providers. Healthcare providers get more forms to fill, and the National Health Financing Authority gets more staff to push more papers. Admin cost will surely go up commensurate with admin paperwork. Admin paperwork usually results in delay in providing care. Whether or not the National Health Financing Mechanism have a profit incentive or nor, remains to be seen. Basically, healthcare cost will not go down. It will at best remain the same, and at worse go up, without improvement in health for the country.

It is also not pointed out, that with this transformation, more money have to be collected from the “rakyat”. What the DG is saying is that the tax that we are providing now, is insufficient ( although we are only using 2.5% of government revenue on Healthcare), and so they need to collect more money from the rakyat ( in the form of direct or indirect taxation ), to park the money in a National Healthcare Financing Mechanism, for use in a transformed healthcare system. For the information of the public, that means to collect more taxes, to raise RM 35-40Billion dollars for the National Healthcare Financing Mechanism. Can you imagine what will happen to the RM 35-40 billion? Are you prepared to put your money into a common pool, having slogged to build up your own savings? Why should one put their money into a common pool and everyone draws out at your expense? This has happened in some western countries and the system has failed. If we really need to raise a fund for healthcare ( when the need arises ), individual Medisave accounts where whatever you earn is yours and if you do not use it, you can leave it to your children or whoever you like, is more practical. It works better. The government must always look after those who cannot afford. That is their social responsibility. They do collect taxes afterall.

We, the FPMPAM feels that the present healthcare system, though good by all outcome measures does have deficiencies that need to be improved and corrected. All these can be done if the government of the day, will increase healthcare allocation from the current less than 5% of GDP to the WHO recommended or OECD country average of 8-9%. Better healthcare delivery, at no greater expense to the “rakyat”, can be achieved. Healthcare is the responsibility of the government and should not be privatized. It is also an inalienable human right. It is not a privilege.

If the table ain’t broken, why fix it?

Dr Ng Swee Choon

Federation of Private Medical Practitioner’s Association of Malaysia ( FPMPAM ), Medical Affairs Committee.

I am trying very hard to insert the two figures that I attached in my letter. So far, I have been unsuccessful. I do not know how.